GW1--05866_Well Construction - GW1_20230912

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Erh-C..- COO k 14.WATER ZONES y
FROM TO DESCRIPTION
Well Contractor Name 1/_ ft. 1 0 p
ft. ., C. pm
Lis77 P I -7sft. 1ioft. 1
0 .GiPfv,‘
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESSS MATERIAL
I
Company Name OSVP-Got7U 3 0--aoc� ® ft �� ft. �� in. S DQ d Puc -
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS ' MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. U D ft. LI in. SC a LI O P,V)r
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) g- ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® E axtrect + 14 ydapie I r^ l+L�
MonitoringI�ecovery ft.ft. � n
Injection Well: ? �a��'�s
p
Aquifer Recharge Groundwater Remediation © ft. 0 ft. P6 ,/ E D 0 O l bS .
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test . DStormwater Drainage ft. ft. `fi
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) `Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWrock type,pain size,etc.)
ft. ft.
4.Date Weu(s)Completed: )-i 7 02 3 Well ID# A 1-1? i 30 ft. ft. e•L-77t ?1 .
ft. ft.
5a.Well Location:
a i�v ttJ;I born
ft. ft. SEP 3 2 2023
Farciillity/Owner ame Facility IDii(if applicable) ft. ft. Inforlr-w' n Pr:w P��l
oc 5-!"1 f 4;(-(Jay br ft. ft. U`re.a :-Ali
Physical Address,City,and Zip ft. ft-
PerS®eN + 5 21.REMARKS� I
County Parcel Identification No.(PIN) 1� 7 1tLD CE i LR DUE? T v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R.A 3' W Prra 11,
(if well field,one 1at/long is sufficient) 22.Certification:
6.IS are the wells ermanent or Te ra Signature of Certifie e�tractor .Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. •
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well'details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0100 (ft.) 24a.For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: a Ss- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" ,3617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO gig (iu) 24b.For Injection Wells:.In addition to sending the form to the address in 24a
y above, also submit one copy of this form. within 30 days of completion of well
12.Well construction method: Pi;c'- ,! construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / 0 Method of test:8 I OWA ea% 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit.one copy of this form within 30 days of
13b.Disinfection type: I4T N Amount: ct 0 7_. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016